Improving transitional care communication for older Australians from hospital to home: Co‐design of the TRANSITION tool

Abstract This study aimed to develop and evaluate a communication tool to guide transitional care for older patients. Using experience‐based co‐design, a communication tool resulted from the triangulation of data collected from three study phases. From 2015 to 2016, semi‐structured interviews and co‐design focus groups were undertaken with older patients, carers and healthcare practitioners across acute, rehabilitation and community settings. The evaluation phase, conducted in 2017–2018, involved use of the communication tool by healthcare practitioners in a multidisciplinary care team with older patients in acute care and semi‐structured interviews with healthcare practitioners about the acceptability and feasibility of the tool. A total of 103 patients, carers and healthcare practitioners took part. In semi‐structured interviews, patients and carers reported needing to become independent in care transitions, which was supported by discussing the transitional care plan with healthcare practitioners. Interviews with healthcare practitioners identified that their need for fast and safe care transitions was supported by team discussion and by engaging patients and carers in their transitional care plan. Co‐design focus group participants identified principles guiding transitional care including patient‐centred communication. Data collected from semi‐structured interviews and co‐design focus groups were used to develop a prototype communication tool to guide conversations about discharge care between healthcare practitioners and older patients. Following use, healthcare practitioners reported that the communication tool was feasible and acceptable although some nurses perceived that transitional care was not their role. The communication tool provides an evidence‐based resource for ward nurses to support transitional care continuity in multidisciplinary models.


| INTRODUC TI ON
Quality communication between healthcare practitioners and older adults living with chronic disease during care transitions from hospital to home is challenging. This is partly because of systembased barriers limiting available time for communication including rapid bed turnover and service fragmentation (Goncalves-Bradely et al., 2016). Suboptimal transitional care and ineffective communication contribute to re-admission, medication misadventure and falls (Goncalves-Bradely et al., 2016). Using experience-based co-design (co-design), this qualitative study aimed to develop a communication tool to guide conversations about transitional care needs between healthcare practitioners and older patients. In this paper, we report on the co-design methods we used to triangulate three study phases resulting in the development of the communication tool. Detailed discussion of each individual study phase has been published elsewhere (Allen et al., 2018(Allen et al., , 2020.

| Transitional care and communication
Transitional care refers to interventions that promote safe and timely transfer of patients between levels of care and across care settings (Coleman et al., 2006;Naylor et al., 2013). Previous research has demonstrated the effectiveness of advanced practice nurses, self-management coaching, discharge case management and multidisciplinary models in facilitating care transition and preventing re-admission (Coleman et al., 2006;Hickman et al., 2015;Jeffs et al., 2017;Naylor et al., 2013). However, effective communication to improve care transition is a persistent challenge in practice.
Recent research has identified the need for more person and family-centred transitional care emphasising improved communication between healthcare practitioners and older adults (Aase & Waring, 2020). However, in transitional care research, communication has been largely understood as the exchange of information between healthcare practitioners (Goncalves-Bradely et al., 2016;Jeffs et al., 2017). A systematic review by Foster and Manser (2012) found that patient hand-over communication at transitions between providers focussed on information exchange in the form of patient checklists. However, there is mixed support for the effectiveness of checklists and a need to examine other forms of communication such as mnemonics to guide hand-over communication (Foster & Manser, 2012). A study by Jeffs et al. (2017) employing an expert panel to identify effective nurse-led transitional care, also recommended further research to examine communication in the form of discussion and conversation between healthcare practitioners, older patients and informal unpaid carers (carers). In a recent metasynthesis study conducted in the early phases of the current study, we identified questioning, discussion, information provision and information seeking as effective communication strategies for healthcare practitioners, older patients and their carers in navigating care transitions (Allen et al., 2017). Despite this research, few studies have developed a communication tool emphasising questioning and discussion between practitioners and older patients in transitional care. A tool promoting communication between practitioners and older patients could improve person-centred transitional care. This study aimed to co-design a communication tool to guide conversations about transitional care needs between healthcare practitioners and older patients returning to the community.

| ME THODS
The consolidated criteria for reporting qualitative studies (COREQ) were used to guide the reporting of the methods (see File S1). The study was informed by co-design principles (Bate & Robert, 2007) and data collection tools and interview guides were developed by our earlier meta-synthesis review (Allen et al., 2017). The lead author is a community nurse with a research background in improving discharge and transitional care of older patients from hospital to home. Any potential influence of the lead author's preconceptions was interrogated by co-authors during checks for dependability and confirmability as part of data analysis in each phase.

| Conceptual framework
The conceptual framework is social constructivism, understood as social processes simultaneously creative of and created by people through interactions with their social context, and with each other (Silverman, 2013). Social constructivism was selected because it What is known about this topic?
• Optimal communication is challenging during care transitions because of rapid bed turnover.
• Few communication tools emphasising discussion between practitioners and older patients in transitional care have been developed.
• Experience-based co-design has not been used in improving transitional care communication for older patients.

What this paper adds?
• The TRANSITION tool is for use by ward-based nurses to guide continuing conversations with patients, monitoring and referral to allied health professionals prior to the patient's discharge.
• Further research is required to evaluate the effectiveness of the TRANSITION tool across the patient transition into the community.
• The role of patients and carers in using the TRANSITION tool to take part in their own care transitions requires further investigation.
conceptualizes interactive social processes, including communication, that are the focus of the study aim. User experience was the principal form of knowledge driving the study and refers to how the user of a health service feels and thinks about the service while they are using it (Bate & Robert, 2007). The social world, particular to the healthcare environment, shapes users' interpretations of the meaning of their experiences of healthcare, and users' interpretations of the meaning of their experiences of healthcare can in turn shape the social world of the relevant healthcare environment. Hence, user experience in healthcare contexts, including transitional care, is itself a social process and formed the principal meaning unit for this qualitative investigation.

| Design
Co-design was used with mixed methods data collection across three phases. Co-design is a participative action research method where service users, including patients, carers/families and healthcare practitioners and providers collaborate to design health services (Bate & Robert, 2007). In a survey study, Donetto et al. (2014) found that co-design has been used in several western countries in a range of specialisations including cancer, mental health, drug and alcohol and emergency departments. To date, few studies have employed co-design to involve service users in optimal transitional care communication and experiences.
In this paper, we report on three study phases from which the results were triangulated to develop the communication tool. The first phase was a context inquiry, conducted from 2015-2016, including semi-structured interviews with older patients and their carers, and with healthcare practitioners to ascertain the practice context. The second phase was undertaken in 2016 and included co-design focus groups where participants were invited to provide feedback on the findings from the context inquiry, derive principles from which to design the communication tool, and check the appropriateness of the prototype communication tool. In the final phase, conducted from 2017 to2018, healthcare practitioners used the tool with an older patient and then participated in a semi-structured interview regarding the acceptability and feasibility of the tool. Drawing on Teddlie and Tashakkori (2009) and Ritchie and Ormston (2014) we understand acceptability and feasibility as the suitability and practicality of the tool including enabling and constraining factors. Data from the final phase informed the modification of the communication tool.

| Ethics approvals
Ethics approvals for the context inquiry, co-design and evaluation phases of the study were obtained from participating healthcare organisations and from the University. Participation in each phase was voluntary. Participants signed a consent form following explanation of the study and requirements guided by an Explanatory Statement as relevant to the study phase. All data were de-identified. All interviews were audio-recorded for transcribing.

| Setting
A large metropolitan public healthcare network, general practice and two community care organisations in the Australian city of Melbourne formed the setting for the context inquiry. Patients and carers, and healthcare practitioners were recruited from two inpatient sites including a ward providing acute general medicine services, and a ward providing rehabilitation services for older people.
Healthcare practitioners were recruited from aged care and rehabilitation services at the public healthcare network, general practice and from the participating community-based organisations.

| Participants: patients and carers
Using purposive sampling for maximum variation regarding age and country of birth, up to 20 patients, plus or minus their carer, were selected to participate in a semi-structured interview. Patients were eligible when they had transitioned from hospital to home, were aged 70 years or older, lived with at least one chronic health problem, and spoke English sufficiently to provide informed consent. Carers were unpaid carers providing support to the older patient and included family and friends. Carers were nominated by participating patients and were eligible to participate when they were at least 18 years of age and spoke English sufficiently to provide informed consent.
Patients and carers with cognitive impairment were excluded.
Codes and categories that were similar to each other were identified following 12 interviews. Because of the difference between acute and rehabilitation ward settings, we conducted an additional eight interviews to check for new codes and categories. No new codes and categories emerged indicating that data saturation was established with a total of 20 interviews.

| Participants: healthcare practitioners
To be included, healthcare practitioners needed to be employed by a participating organisation and provide transitional care to older patients and their carers. Purposive sampling, using maximum variation for healthcare discipline and setting, was used to invite participants for a semi-structured interview and included multidisciplinary practitioners across acute, rehabilitation and community settings.
During data collection that commenced in the acute general medicine inpatient ward, participants reflected on the range of publicly funded programs used by older adults undergoing care transitions and living with multiple chronic diseases in the acute, rehabilitation and community settings. These programs included general medicine (acute inpatient), Hospital in the Home (acute community), Geriatric Evaluation and Management (rehabilitation inpatient), Aged Care Consultancy and Triage (rehabilitation inpatient), Post-acute Care (rehabilitation community), Transition Care Program (rehabilitation inpatient and community), Aged Care Case Management (community), District Nursing (community) and General Practice (community/primary care). To describe the context of care transitions for older adults, we aimed to include at least two healthcare practitioners per program and at least one healthcare practitioner per discipline as relevant to the program. We identified similar codes and categories following 30 interviews. To ensure data saturation within each of the nine health programs we conducted an additional 17 interviews with no new codes or categories emerging. Following completion of 47 interviews, we concluded that we had reached data saturation.

| Data collection tools and interview guides
A semi-structured interview guide was developed using the recommendations of Bate and Robert (2007) and using the meta-synthesis review conducted earlier (Allen et al., 2017). All participants com-

| Procedure
Senior nurses on each ward were invited to identify patients who met the inclusion criteria and introduce the study to them. With patients' permission and using the ethics approved Participant Information and Consent Form (PICF), the first author explained participation in the study and then conducted a face-to-face semistructured interview with the patient in their own home at least one week following hospital discharge. The first author is female and is an experienced registered nurse, educationally prepared at Masters level with skills in interviewing patients and research participants.
Patients who agreed nominated their carer who was also invited to participate in the interview.
Management at each site nominated key personnel involved in transitional care who met the inclusion criteria. With permission and using the PICF for healthcare practitioners, the first author invited practitioners to participate in the study and conducted face-to-face semi-structured interviews in participants' place of employment during a scheduled meal break or in an office at the university.
Permission was requested from patients who had participated in the semi-structured interviews for the first author to contact their general practitioner (family physician). The first author invited general practitioners to participate in the study and sent the PICF for healthcare practitioners by email. The first author then contacted the general practitioner by telephone, explained participation in the study and conducted a telephone interview at an agreed time.

| Setting
The setting was the same as noted earlier.

| Participants
In accordance with co-design principles (Bate & Robert, 2007), patients, carers and healthcare practitioners were included together as participants in the co-design focus groups. Each focus group comprising the same participants met on three separate occasions.
Participants were recruited purposively, and inclusion criteria were the same as reported above for the context inquiry.
All patients and carers, and healthcare practitioners invited to participate in the context inquiry were invited to participate in the co-design focus groups. One patient, one carer and one healthcare practitioner responded. The remaining patients declined to participate due to frail health. Remaining carers declined to participate due to lack of time. Healthcare practitioners declined further participation because of lack of time. Therefore, a recruitment invitation was included in the staff newsletter for the healthcare network and each community organisation was sent a recruitment invitation. The recruitment strategy resulted in an additional four healthcare practitioners. One of the healthcare practitioners was also an informal carer. In accordance with Silverman (2013), seven participants were considered an adequate number for interaction within a small group.
Three co-design focus groups were conducted.

| Data collection tools and interview guides
For the context inquiry study, data collection tools and interview guides were developed from the meta-synthesis review conducted earlier (Allen et al., 2017). In the first co-design focus group, all participants completed a demographic questionnaire including information about their: age; gender; country of birth; health status (for patients and carers); education, current role and healthcare discipline (for healthcare practitioners). In focus groups 1 and 2, we presented a summary of the themes from the findings in the context inquiry. In focus group 1, the questions 'Do the findings make sense? How/how not?' were used to guide the discussion. In focus group 2, participants were invited to imagine the ideal discharge and care transition. We used the question 'What are the "must haves" in discharge and transitional care?'. In focus group 3, we presented the prototype communication tool. We used the questions 'Does the tool make sense?' and 'What could be improved?'.

| Procedure
The focus groups were scheduled at three time points with a oneweek interval between the first and second focus groups, and a 2- week interval between the second and third focus groups to allow sufficient time to develop the communication tool. The three focus groups were facilitated by the first author using the interview guides noted above. A research assistant supported each of the focus groups by assisting participants to complete the demographic questionnaire and by observing the group dynamics and documenting these in field notes.

| Setting
The setting comprised two acute medical wards in one public health network in suburban Melbourne Australia. This public health network was a different organisation from the organisation that participated in the context inquiry and co-design focus groups. To maximise sampling heterogeneity, healthcare practitioners were recruited from a range of disciplines including nursing and allied health.

| Participants
Purposive sampling was used to recruit healthcare practitioners from participating wards and programs who were aged 18 years or older and conducted transitional care of older patients. Nurse Unit Managers at the participating wards and management staff at the health network invited healthcare practitioners who met the inclusion criteria to consider participation in the study. With healthcare practitioners' permission and using the ethics approved PICF, the lead author or research assistant explained all requirements of participation in the study to them including details about the communication tool, use of the tool and evaluation steps. Codes and categories that were similar to each other were identified following 18 interviews. Five additional interviews were undertaken with no new codes and categories emerging. We, therefore, considered that we had reached data saturation after 22 interviews.

| Data collection tools and interview guides
Data collection tools and interview guides comprised screening and demographic questionnaires and a semi-structured interview guide.
These were developed from previous study phases. Screening and demographic questionnaires included information about the par- Practitioners were given a copy of the semi-structured interview guidelines to use as a guide in making notes regarding their experience. Following use of the tool with at least one patient or carer, practitioners were invited to participate in a semi-structured interview. Interviews were conducted by either the first author or a research assistant at the participant's work location during a scheduled meal break. The research assistant was a female registered nurse educationally prepared at Bachelor degree level. The research assistant in the evaluation study phase was different from the research assistant who assisted with the second study phase.

| Data analysis
Quantitative data were entered into SPSS for descriptive statistics including frequencies and means. Qualitative data were thematically analysed by the lead author in collaboration with the other authors.
A summary of each study phase, data collection tool and interview guidelines, data and data analysis is presented in Table 1.
Interviews were thematically analysed separately for each study phase. Thematic analysis was an iterative process and supported by the Framework Approach (Spencer et al., 2014). Using the research aim and rationale for data collection as guides, thematic analysis involved comparing and contrasting of codes and categories within and where relevant between interviews to derive a plausible formulation of the data. All authors coded raw data files and interrogated interpretations made by the first author.

| Triangulation of findings and rigour
Triangulation between study phases was employed to co-design the communication tool in two parts; (1) tool development; and (2) evaluation. Findings from the context inquiry were presented to participants in the co-design focus groups for validation, for their consideration of principles to guide the development of the tool and to provide feedback on the prototype tool. Findings from the evaluation were used to refine the tool. Triangulation of findings was further supported during meetings where all authors interrogated interpretations made by the first author to develop, evaluate, and refine the communication tool.
We applied the principles of trustworthiness as proposed by Lincoln and Guba (1985) to describe the process of triangulation: credibility, transferability, dependability and confirmability. Credibility is supported through prolonged observation occurring over the three study phases (Silverman, 2013;Teddlie & Tashakkori, 2009). Because multiple data sources were used, a multi-perspective description of communication in transitional care practice between healthcare practitioners, older patients and carers also supports the credibility of the study (Silverman, 2013).
Detailed description of the study context was the focus of the context inquiry, which should enable others to consider how the communication tool, or elements of it, might be applied to similar contexts of care. TA B L E 1 Summary of data collection tool and interview guidelines, data and data analysis for the three study phases Data analysis for each phase of the study and related inferences about the data including the triangulation of findings, were examined for consistency through dependability and confirmability checks (Silverman, 2013;Teddlie & Tashakkori, 2009). In these checks, all authors reviewed raw data files and interrogated interpretations made by the first author. Confirmability was further supported through the co-design focus groups, when participants had the opportunity to provide feedback on the findings from the context inquiry and on the communication tool. In triangulating the findings, the first author referred to field notes she made throughout data collection and to field notes made by the research assistants, which also supported dependability and confirmability.

| FINDING S
A total of 103 patients, carers and healthcare practitioners took part across the three study phases.

| Patients and carers
A total of 20 interviews were conducted with 26 patients and carers.
Thirteen patients were interviewed alone, six patients were interviewed together with their carers (6 carers) and one carer was interviewed alone. All patients and carers emphasised that becoming independent was the problem to be solved in care transitions. They reported that caring relationships with healthcare practitioners and discussing and negotiating the transitional care plan supported their return to independence after hospital discharge.

| Co-design focus groups
Of the seven participants recruited, all took part in the first codesign focus group, three participants took part in the second focus group and five participants took part in the third focus group. Participants who were unable to attend each focus group noted that this was due to insufficient time or illness. In the first and second co-design focus groups, participants endorsed findings presented to them from the context inquiry. The health practitioner participants also reported that the problem to be solved in transitional care was 'needing the bed'.  Table 4). These principles were used to guide the development of questions comprising the prototype communication tool. In the third co-design focus group, participants endorsed the prototype communication tool and suggested additional prompts and questions resulting in the trial version of the communication tool, the TRANSITION tool (presented in Table 5).

TA B L E 2 Participant characteristics, data saturation and interview details: context inquiry, co-design focus groups and evaluation study phases
Rationale for data collection

Duration and place of interviews
Interviewer details a

Context inquiry: patients and carers
To describe older patients' and informal carers' experience of transitional care 20 semi-structured interviews, 26 participants: • 13 interviews with individual patients • 6 interviews with patient and carer dyads • 1 interview with individual carer Demographic details for all 19 patients: • Mean age 82.6 years (SD 6.6 years, range 72-94 years) • 11 were female Demographic details for all 7 carers: • Mean age 68.9 years (SD 14.1 years, range 45 to 88 years) • 5 were female • 6 family members (4 spouses, 1 daughter, 1 son) • 1 friend and neighbour • Similar codes and categories were identified following 12 interviews.
• An additional eight interviews were undertaken with similar results indicating that data saturation was established.
• Interviews were on average 37 min duration

| Healthcare practitioners
A total of 22 healthcare practitioners from nursing, occupational therapy, physiotherapy, social work and pharmacy took part in the evaluation. All six medical practitioners on each medical ward were invited to take part; however, they declined due to lack of time. Following application of the TRANSITION tool with an older patient in an acute medical ward, healthcare practitioner participants reflected that the tool was feasible and acceptable. Nurse participants reported that the tool was an acceptable and clear set of questions assisting them to screen and assess patients, engage patients in a conversation about their discharge, and support their understanding of the patient in the community. Most nurse participants commented that the tool supported them to know what to ask and assisted them to find more information about the patient at home as part of an informal conversation. They noted TA B L E 4 Principles identified from co-design focus groups 1 and 2 Eight principles were identified for quality transitional care to guide the development of the communication tool.

Healthcare practitioners need to remain patient-centred
Healthcare practitioners need to ensure patient flow through the healthcare system Healthcare practitioners need to use multidisciplinary teams and aged care expertise regarding assessment, planning (cognition, mobility and falls risk, side effects of medications) and service navigation in the community Healthcare practitioners, patients and informal carers need to relate respectfully, effectively and empathically with each other Healthcare practitioners should involve the patient, family and carers in discussions about discharge and transitional care Older patients need quality and safe medication care and preparation at discharge Patients, carers and families need education and support, including emotional support, in regard to discharge and care transitions • How does the person function at home/remember to do the usual things (making a hot drink, making a meal, eating, sleeping, taking medicines, conversation, getting out of bed, getting dressed appropriately for weather and activity)?

TA B L E 5 Communication tool: the TRANSITION tool
Services at home: Who visits already and who might need to visit?
• Who normally visits at home to assist with care?
• Does the person live alone -they may need a little more assistance to fully recover? • Do services need to visit more regularly in the immediate follow-up period?
• Is there a need for formal services after discharge?
Injury risk at home: What is the home environment like?
• How does the person move around at home? Do they fall? • Hazards and risks (stairs, rugs, clutter creating tripping risks)?
• Do the person and carer know about safety alarms at home and how to access these?
Tablets and medicines • How does the person manage to take their medicines?
• Who helps them to take their medicines?
• Do they know about aids from their local chemist that can help such as blister packs?
Instructions and self-care education • What do the person and carer need to know about looking after themselves at home? What information do they need? Who do they need to ask about self-care at home? • The first week home is challenging and confidence is critical. Encouragement, positive attitude and acknowledging the small steps are important.
Organisation of discharge: Where is the discharge plan up to and who knows about it?
• Has the person and carer been involved in the discharge plan?
• Has the carer/family been notified of changes in the discharge plan?
• Where is the person going to go?
Needs and concerns: note any other concerns • Any other concerns about discharge and going home?
• Any concerns about being at home? that this was not usual practice on their wards. One registered nurse (participant 1) noted 'Being able to ask those questions that I do not necessarily ask. In terms of how well they are looking after themselves at home. Are they able to cook and clean for themselves? Because we don't always ask our patients that as nurses'.
Other nurse participants stated that the tool assisted them to continue the discharge planning initiated in the emergency department by the allied health professionals and to check for care needs that may have been missed. Allied health participants agreed with these comments and reported that they asked similar questions as relevant to their discipline in their own assessment tools.

| Modification of the communication tool
We used the evaluation findings to modify the TRANSITION tool (presented in Table 5). The main modifications included adding a column labelled 'date completed' and making the tool more succinct to promote continuity and because ward-based nurses had limited time to engage patients in conversations.  (Hickman et al., 2015). The current study is one example of how a communication tool can support multidisciplinary teamwork through ward nurses' identification of care issues that they then refer to allied health practitioners.

| DISCUSS ION
The need for holistic transitional care planning from a multidisciplinary perspective that includes consideration of the patient at home is challenging for inpatient healthcare practitioners, patients and carers (Coleman et al., 2006). This is because the home environment and supports are generally unknown to inpatient practitioners and because patients' recovery care needs may be unknown to patients and carers (Naylor et al., 2013). The use of the communication tool cannot be claimed to address these issues.
However, findings indicate that in using the TRANSITION tool some ward nurses considered the patient's care needs at home and this was not their usual practice. This suggests that the communication tool may assist ward-based nurses to improve person centred transitional care and bridge the hospital to home boundary.
In addition, the finding that some ward nurses' use of the com-

| FURTHER RE S E ARCH
Further research is required to evaluate the acceptability and feasibility of the tool for patients and carers and to test the effectiveness of the communication tool across the patient transition into the community. The role of patients in using communication tools to take part in their own care transitions requires further investigation.

| LI M ITATI O N S
There are several limitations to the current study. Conversational style communication involving questioning and discussion is a twoway process. However, the current study only evaluated nurses and allied health practitioners' use of the tool. The role of patients and of informal carers was not explored in the evaluation and their perspectives about using the communication tool are not known.
We elected to sample healthcare practitioners from nursing, allied Implementation of a communication tool such as the TRANSITION tool will require a carefully planned strategy to ensure an optimal fit with current practices and to engage ward-based nurses. This will require education that includes explicit comparison between existing systems of care, practice gaps and how the communication tool could strengthen transitional care systems in healthcare services.

ACK N OWLED G EM ENTS
We gratefully acknowledge all participants in this study and the sup-

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest in this study.

AUTH O R CO NTR I B UTI O N S
JA led the conceptualisation and design of all phases of the study with support from all co-authors, JA undertook all data collection with support from two research assistants in the co-design focus groups and evaluation phases, all authors contributed to data analysis, all authors contributed to the writing of the manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing not applicable.